|Year : 2021 | Volume
| Issue : 3 | Page : 113-118
Impact of COVID-19 pandemic on physical and rehabilitation medicine residents in the Americas
Manoj K Poudel1, Alessandro de Sire2, Constanza Leal Johnson3, Francisco De la Rosa-Morillo4, Javier R Delgado-Martínez5, José A Neira Lázaro6, Kevin A Portillo-Koberne7, Leandro R Iuamoto8, María A Jiménez León9, Maria Fernanda Calderón-Solis10, María T Romo Rosas11, Natalia A López Rivas12, Patricia Marisol Aliaga Jiménez13, Raisa M Zuwolinsky Elguera14, Tiffany Lau15, Veronica C Bouché16, Alejandro Asial17, Eva C Miguel Reyes18, Carolina Schiappacasse19, Walter R Frontera20
1 International Society of Physical and Rehabilitation Medicine – World Youth Forum, Milan, Italy; Department of Physical Medicine and Rehabilitation, University of Miami/Jackson Health System, Miami, USA
2 International Society of Physical and Rehabilitation Medicine – World Youth Forum, Milan; Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, Cantanzaro, Italy
3 Department of Physical Medicine and Rehabilitation, University of Chile Clinical Hospital, Santiago, Chile
4 Department of Physical Medicine and Rehabilitation, Plaza de la Salud General Hospital/Universidad Iberoamericana, Santo Domingo, Dominican Republic
5 Department of Physical Medicine and Rehabilitation, National University of Colombia, Bogota D.C, Colombia
6 Department of Physical Medicine and Rehabilitation, Virgen de la Puerta Hospital – Essalud, Trujillo, Peru
7 Department of Physical Medicine and Rehabilitation, University of San Carlos of Guatemala/Gautemalan Institute of Social Security, Guatemala City, Guatemala
8 Department of Physical and Rehabilitation Medicine, Institute of Physical and Rehabilitation Medicine, Clinics Hospital - University of São Paulo Medical School, São Paulo, Brazil
9 Department of Physical Medicine and Rehabilitation, Social Security of Ecuador State Hospital/Specialty Hospital Teodoro Maldonado Carbo, Guayaquil, Ecuador
10 Department of Physical Medicine and Rehabilitation, National Autonomous University of Honduras, Tegucigalpa, Honduras
11 Department of Physical Medicine and Rehabilitation, Regional Hospital “1° de Octubre”/National Autonomous University of Mexico, Mexico City, México
12 Complejo Hospitalario Dr. Arnulfo Arias Madrid/Caja de Seguro Social, Panamá, Panamá
13 Department of Physical Medicine and Rehabilitation, Bolivian Rehabilitation Institute, La Paz, Bolivia
14 Department of Physical Medicine and Rehabilitation, University of Costa Rica, San Jose, Costa Rica
15 Department of Physical Medicine and Rehabilitation, Burke Rehabilitation Hospital, New York, USA
16 Department of Physical Medicine and Rehabilitation, Children's hospital Sister María Ludovica - La Plata, Buenos Aires, Argentina
17 Department of Physical Medicine and Rehabilitation, Hopsital of Rehablitation Manuel Rocca - Caba, Buenos Aires, Argentina
18 Department of Physical Medicine and Rehabilitation, Clínica de Rehabilitación “Raquel”/Hospital Regional 1o Octubre, Oaxaca, México
19 Department of Physical Medicine and Rehabilitation, British Hospital/Rehabilitation Clinic Las Araucarias/San Martin University, Buenos Aires, Argentina
20 Department of Physical Medicine, Rehabilitation, and Sports Medicine, University of Puerto Rico School of Medicine, San Juan, Puerto Rico
|Date of Submission||05-Sep-2019|
|Date of Decision||02-Feb-2021|
|Date of Acceptance||03-Mar-2021|
|Date of Web Publication||20-Jul-2021|
Dr. Manoj K Poudel
Department of Physical Medicine and Rehabilitation, University of Miami/Jackson Health System, 1611 NW 12th Ave, Miami, FL 33136
Source of Support: None, Conflict of Interest: None
Introduction: Coronavirus disease 2019 (COVID-19) pandemic has affected the physical and rehabilitation medicine (PRM) specialty globally. The effects of this pandemic on PRM residents in 14 countries of the Americas are described in this study. Materials and Methods: This study is based on the international survey done by the World Youth Forum of the International Society of Physical and Rehabilitation Medicine. The cross-sectional data obtained were analyzed for a point-of-view study (August 2020). Results: PRM residents reported multiple challenges in their training program including mental health issues during the pandemic. In all the countries, there was either complete or partial closure of services provided by PRM specialists at the height of the crisis. In some areas, there was a necessity to temporarily transform the rehabilitation service into a COVID-19 unit and to assign residents to medical and intensive care units. Residency programs in 13 countries introduced virtual lectures and examinations. The duration of residency will probably increase in three countries, may not be affected in another six, and is still undetermined in five. The specialty licensing examination was temporally suspended/postponed in four countries, administered in a modified way in one, and has not been affected yet in four. Conclusion: COVID-19 pandemic adversely affected the training of PRM residents in the Americas. Despite the efforts to overcome this, the residents need more support including well-being programs. Every country and training program should continue to evolve to adapt to the crisis and anticipate additional challenges in the near future.
Keywords: Americas, coronavirus disease 2019, International Society of Physical and Rehabilitation Medicine, International Society of Physical and Rehabilitation Medicine World Youth Forum, physical and rehabilitation medicine residents
|How to cite this article:|
Poudel MK, de Sire A, Johnson CL, De la Rosa-Morillo F, Delgado-Martínez JR, Neira Lázaro JA, Portillo-Koberne KA, Iuamoto LR, Jiménez León MA, Calderón-Solis MF, Romo Rosas MT, López Rivas NA, Aliaga Jiménez PM, Zuwolinsky Elguera RM, Lau T, Bouché VC, Asial A, Miguel Reyes EC, Schiappacasse C, Frontera WR. Impact of COVID-19 pandemic on physical and rehabilitation medicine residents in the Americas. J Int Soc Phys Rehabil Med 2021;4:113-8
|How to cite this URL:|
Poudel MK, de Sire A, Johnson CL, De la Rosa-Morillo F, Delgado-Martínez JR, Neira Lázaro JA, Portillo-Koberne KA, Iuamoto LR, Jiménez León MA, Calderón-Solis MF, Romo Rosas MT, López Rivas NA, Aliaga Jiménez PM, Zuwolinsky Elguera RM, Lau T, Bouché VC, Asial A, Miguel Reyes EC, Schiappacasse C, Frontera WR. Impact of COVID-19 pandemic on physical and rehabilitation medicine residents in the Americas. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2021 Dec 6];4:113-8. Available from: https://www.jisprm.org/text.asp?2021/4/3/113/321979
| Introduction|| |
Coronavirus disease 2019 (COVID-19) has spread to 213 countries and territories around the world infecting more than 25 million people and causing over 850,000 deaths as of August 2020. The Americas is one of the worst hit regions of the world and six of the countries, United States of America (USA), Brazil, Peru, Mexico, Colombia, and Chile which are included in this study, ranked in the top ten globally in terms of the number of cases. Chile, Panama, and the USA ranked in the top ten in the number of infections per million inhabitants. Further, the USA, Brazil, and Mexico ranked in the top three countries in mortality, while Peru, Chile, and USA were in the top ten in terms of mortality per million inhabitants. However, none of the 14 countries included in the study were in the top ten for number of tests per million population.
COVID-19 pandemic has been a challenge for the medical community. Globally, physical and rehabilitation medicine (PRM) specialists have been facing many challenges including the interruption of rehabilitation services and requirements to modify standard practice. The education and learning process of in-training PRM physicians has also been adversely affected. Despite the challenges, the PRM residents contributed to the handling of global pandemic by treating COVID-19 patient both in acute and rehabilitation care settings. Hence, the purpose of this study was to describe and analyze the experiences and the challenges faced by the PRM residents in the Americas and to contribute to the discussion on how to address these very unusual educational challenges.
| Materials and Methods|| |
Study design and participants
This is a cross-sectional, point-of-view, study of countries in the region of the Americas. The first author submitted a proposal to conduct a survey regarding the challenges faced by PRM residents during the COVID-19 pandemic in the meeting of the central and regional leaders of International Society of Physical and Rehabilitation Medicine World Youth Forum (ISPRM-WYF) which was also attended by the members of ISPRM President's Cabinet. A consensus was reached to conduct a survey and investigate the impact of COVID-19 on the PRM residencies. The first and senior authors were assigned to design a survey questionnaire. The targeted group to fill the designed survey was the Country Ambassadors (CAs) of the ISPRM WYF in the Americas.
Data collection and analysis
The survey form included 15 questions [Table 1] related to the COVID-19 pandemic and its effects on the PRM specialty services and residency training programs. We described for each country the number of inhabitants, PRM residency training programs, residents, and the reported statistics of the number of COVID-19 cases. These questions were important to include to understand overall experiences and situations of residents and residencies and to compare with other countries in the region and with other regions of the world. The submitted reports were individually analyzed. Common and trans-national adverse consequences of the pandemic along with the contributions of the PRM residents to fight the crisis were identified.
| Results|| |
The response rate to the survey filled by the CAs with the help of their respective PRM national societies was 100%.
Country-specific status of physical and rehabilitation medicine residents during the pandemic
The country-specific brief demographic data of population, disability, COVID-19 and PRM specialty and the impact of COVID-19 on the specialty are listed in [Table 2] and [Table 3].,
|Table 2: Population, disability and coronavirus disease 2019 situation in the countries in the Americas as of August 2020|
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|Table 3: Physical and rehabilitation medicine specialty and the impact of coronavirus disease 2019 in the Americas as of August 2020|
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There are 19 PRM residency programs with approximately 80 residents in Argentina. During the pandemic, outpatient care and procedures were suspended in most programs. On the other hand, most inpatient rehabilitation services continued to operate, but length of stay was shortened resulting in an interruption of the rehabilitation process. Many residency training programs continued teaching in virtual format, while others suspended academic activities. All residency-related examinations were postponed.
Bolivia has five PRM residency programs and 28 residents in training. The number of outpatient and procedure clinics was reduced but not completely closed. In some centers, telemedicine was established to continue with the outpatient rehabilitation programs. Bolivia is working on formulating protocols to take care of COVID-19 patients in ambulatory settings. Only the Bolivian Institute of Rehabilitation hospitalized patients for acute rehabilitation but has not yet started accepting COVID-19 patients. At first, lectures and conferences were suspended. Then, virtual lectures were started. In some centers, the residency-related examinations were canceled; in others, they were conducted virtually.
Brazil has the second highest number of COVID-19 infections in the world after the USA. There are 17 PRM residency programs with about 84 residents. Residents have been re-assigned to COVID-19 wards and intensive care units (ICUs), resulting in a delay in their PRM residency training of several months. The exposure to outpatient experiences and procedures has been low due to fear of patients to come to the clinic. Rehabilitation wards have been re-dedicated to COVID-19 patients. The number of patients in the inpatient rehabilitation has decreased. Some teaching activities are being conducted virtually.
Chile is in the top ten in the world for the number of total number of COVID-19 infections. It has about 60 residents in four PRM residency training programs. In some of the larger medical centers, PRM residents had to work in hospital wards dedicated to COVID-19. Outpatient care and procedures as well as inpatient rotations were suspended in all programs at the end of March. Virtual educational activities have been implemented. Starting in August, some in-hospital rotations started to gradually accept residents. Written examinations have been administered using online platforms, but practical examinations have been postponed. Two programs conducted the licensing evaluation online, one program exempted the examination for graduates with satisfying performance during their residency, and one had already completed the training before COVID-19 crisis started.
The country is in the top ten in the world for the number of total infections. Colombia has six PRM residency programs and approximately 90 residents. At the worse of the pandemic, the number of patients in outpatient clinics decreased by about 80%. Hence, telemedicine services have been used extensively. Electrodiagnostic studies are done with precautions and the use of personal protection equipment. At one point, Colombia reached an occupancy of 95% of ICU beds due to increased cases of severe COVID-19 cases. Inpatient rehabilitation services were reduced to accommodate for COVID-19 patients. At the beginning of the lockdown, academic activities were converted to a virtual format. Now, with the progressive opening of clinics, lectures and examinations have returned to a more normal routine but continue to be offered using virtual platforms.
The country has one rehabilitation center with up to 12 residents per year based on the national needs. The center was designated as the Specialized Center for the Attention of COVID-19. Shortly after the pandemic started, the inpatient and outpatient rehabilitation services were suspended, and 12 days later, telemedicine via phone was started. In Costa Rica, some residents were reassigned to other hospitals with only outpatient PRM services. PRM procedures were resumed 2 months after the beginning of the pandemic. Face-to-face evaluation of patients has slowly started again. However, residents are not getting sufficient clinical experiences. Lectures are being conducted virtually. Residency-related examinations were converted to written projects or canceled. On July 29, 2020, the residency program was temporarily suspended with most of the residents reassigned to COVID-19 units.
There are two PRM residency programs with a total of 14 residents. Due to the pandemic, the residents were assigned to internal medicine (IM) services. Outpatient clinics were closed for the first 6 weeks and then resumed as the COVID-19 cases started to decrease. There are no acute inpatient rehabilitation services in the Dominican Republic. The hospital-based services of PRM specialists were resumed in May 2020. The teaching sessions have been completed virtually. The pandemic has not affected the residency-related examinations.
In Ecuador, there is one PRM residency program in Guayaquil at the Ecuadorian Social Security Hospital with a total of four residents. Because of local political issues, there has not been recruitment of new residents since 2018. Since early March, residents were relocated to the areas of greatest clinical needs such as ICU and IM services. The academic lectures were put on hold. Since mid-May, residents were able to return to their inpatient and outpatient services and the teaching sessions were reinitiated virtually. Examinations and research activities were put on hold until mid-July.
There are two PRM residency programs with a total of 40 residents. Since March 2020, outpatient services and clinical rotations (both inpatient and outpatient) have been suspended. Many of the hospitalized patients were sent home, and residents have been helping in the COVID-19 attention areas. The inpatient rehabilitation beds were used to admit COVID-19 patients as the number of COVID-19 patients requiring acute hospital admission increased. Telemedicine has been used to conduct clinical evaluations and therapy sessions. Some patients have been scheduled for electrodiagnostic studies, if necessary. Lectures, examinations, and academic evaluations were continued with precautions.
There is one PRM residency program with a total of 15 residents in Honduras. The residents rotate in five different hospitals in two cities. A week after the first case, all the residents were asked to stay home as a precaution. Lectures were conducted virtually including weekly meetings to discuss scientific papers on COVID-19. After 6 weeks, telemedicine services were started along with outpatient recovery services for COVID-19 rehabilitation. Inpatient rehabilitation was resumed in May, especially for COVID-19 patients. In July, electrodiagnostic procedures were started. In the same month, the Higher Education Council of Honduras authorized online examinations and teachers began to prepare for this.
The country has 12 PRM residency programs and a total of 280 residents. Mexico also has subspecialty fellowship training in pulmonary rehabilitation. The country is currently in the top ten in the world in number of infections. All outpatient services were closed to give priority to COVID-19 patients. All classroom activities were suspended, and virtual classes were implemented including virtual examinations for some subjects. In April/May, few hospitals resumed inpatient rehabilitation services. Although the government loosened restrictions, most of the rehabilitation hospitals remained closed through July/August because the number of cases of COVID-19 was still very high.
There are two PRM residency programs with eight residents in Panama. The government is discussing a change from the current 3-year program to a 4-year program after 2020. All outpatient services were suspended in March including diagnostic and therapeutic procedures, except for urgent electrodiagnostic procedures. Some residents are rotating with IM and also doing telemedicine. Panama does not have a rehabilitation hospital/center. The care of hospitalized patients by PRM physicians has continued in one acute hospital which has the highest number of COVID-19 patients. All lectures and examinations were suspended in March. Teaching sessions have been conducted virtually and examinations were resumed in August.
There are 11 PRM residency programs with about 450. Peru has the highest mortality rate adjusted per million population in the Americas. A week after the first case, the government declared a national security emergency. Outpatient clinics and procedural services were and remain closed, including the only rehabilitation hospital. Residents were reassigned to other services. The emergency declaration was extended for another 90 days in June. Telemedicine is being used to provide clinical services, and virtual platforms have been used for lectures and academic activities. Most residency examinations have been offered also virtually, but a few have been postponed.
There are 93 PRM residency programs with 480 new residents every year. Currently, the US has the highest number of cases and deaths in the world. The Accreditation Council for Graduate Medical Education formulated a three-stage recommendation for residency programs: Stage 1 – business as usual, Stage 2 – increased but manageable demand, and Stage 3 – routine care education and delivery must be reconfigured to focus only on patient care. Because of the large size of the country, different states were/are at different stages at different times. In the most affected areas, elective procedures and outpatient clinics were suspended, and residents were pulled to COVID-19 wards and ICUs as needed. Some of the hospitals and rehabilitation inpatient wards have been converted to COVID-19 units, during the maximum crisis in hard hit areas such as New York. Telemedicine has been extensively used. In the states where the spread has slowed down, the outpatient and elective procedural services have slowly resumed. The inpatient services have continued to provide services including patients who survived COVID-19 and require extensive inpatient rehabilitation. The lectures and residency-related examinations are being done virtually or in-person with a group of less than 10 persons where possible. The interviews for new residents have been conducted virtually this year.
Other challenges faced by the residents including impact on mental health
In some countries, residents were relocated to different cities to work or were not paid in time which caused a financial burden. In low-resource regions of some countries, residents faced a situation of lack of enough personal protective equipment. Residents also reported a negative impact on their social life and group activities both at and outside hospitals. With the high volume of work and longer work hours, residents in some countries suffered considerable amount of physical and mental stress.
In most countries, part of rehabilitation care relied on telemedicine, but the patient's lack of technological knowledge and healthcare worker's inexperience have made this approach challenging to implement specially in the developing countries.
Mental health has been a big concern for a significant number of residents due to uncertainty in the training program, education, examinations, and career plans. Residents had to adapt to new ways of patient care and education (telemedicine, virtual lectures, and reduced exposure to clinical learning) and coverage of unfamiliar clinical services (emergency departments, COVID-19 units, and ICU) of medicine. There was also fear of contracting the disease and spreading it to vulnerable family members; hence, some residents opted to live away from their families. As the number of cases and mortality increased in many countries, the resident's mental health was affected. For example, in a survey done in Chile, 30% of residents reported to have required psychological/psychiatric support during the pandemic.
Positive messages from the physical and rehabilitation medicine residents
Residents reported that their national societies and programs are trying their best to help them during this crisis, and they have started receiving psychiatric/psychological support. With the help of the ISPRM and regional organizations, the residents were given opportunities to participate in international programs including in research activities. The ISPRM Webinar Series helped residents acquire COVID-19–related PRM information.
| Discussion|| |
The present study shows that the COVID-19 pandemic is having very negative effects on PRM residency training programs as well as positive messages learned during the crisis. The challenges and issues in different countries of the Americas included important changes in the nature of the delivery of PRM services, the assignment of residents to nonrehabilitation care units, and the use of technology to conduct academic and clinical activities. These challenges are very similar to those reported in European countries. Resident education/training is vital in all specialties. The disruption of residency education/training can have long-term effects on not only individual residents but also the specialty and healthcare system as a whole.
With the exception of emergency situations, an effort should be made to maintain residency training, even at times of crisis that may require some modifications in the mode of teaching–learning and delivering patient care. The implementation of newer mode of healthcare delivery techniques, such as telemedicine requires sufficient training before the use. To prevent resident fatigue, the maximum duty hours rules should be formulated and implemented in the countries where it is not existent. While introducing and adapting the content and clinical experiences typical of residency training, the overall situation of residents including their physical and mental health must be taken into consideration. This goal must be discussed with all concerned with the important mission of training the future generation of PRM physicians.
Despite the challenges, the residents took it as a privilege to take care of COVID-19 patient both in acute care and rehabilitation settings. Hence, the pandemic has been a learning, giving, and resilience building opportunity for PRM residents.
| Conclusion|| |
COVID-19 pandemic adversely affected the training of PRM residents in the Americas. Both inpatient and outpatient clinical experiences decreased, and teaching/learning activities were significantly modified. More importantly, the personal life and mental health of the residents were adversely affected because of the additional stress at work, uncertainty of residency training requirements, and concerns about future career plans. The ISPRM, national PRM societies, and individual residency programs have been trying to help the residents to overcome this. However, more support is needed for the residents. Every country and residency training should continue to manage the current crisis and formulate plans for future similar challenges.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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|[Pubmed] | [DOI]|